Sexual Assault Treatment Plan Out-of-State Hospital Form
Sexual Assault Treatment Plan Out-State Hospital Plan
Instructions: This form describes the minimum components of a Sexual Assault Treatment Plan. References to the "Regulations" mean the Illinois Department of Public Health Sexual Assault Survivors Emergency Treatment Code (77 Ill. Adm. Code 545), which implements the Sexual Assault Survivors Emergency Treatment Act [410 ILCS 70] (the Act). All responses shall be written as clearly and succinctly as possible. If additional sheets are necessary, attach those sheets to the page on which the information is originally requested. A completed copy of the plan shall be retained by the pediatric health care facility. The completed plan shall be sent to:
Illinois Department of Public Health Division of Health Facilities and Programs 525 West Jefferson Street, 4th Floor Springfield, Illinois 62761-0001
PART A
Name of Out-of-State Hospital: ______
Mailing Address: ______
Contact Person/Title for Program: ______
______(E-mail) (Telephone Number) (Fax Number)
Contact Person for Billing: ______
______(E-mail) (Telephone Number) (Fax Number)
Area-wide plan with acceptance of transfers of pediatric patients only? Yes No If yes, list the name of the hospital(s) and or pediatric health facility with an agreement.
______
Emergency department attending physicians, physician assistants, advanced practice registered nurses are qualified medical providers as per Section 1a of the Act.
Yes No
If no, describe how the hospital has developed a training program as per Act to complete the minimum two (2) hours of sexual assault training by July 1, 2020, and the minimum two (2) hours of continuing education on responding to sexual assault survivors every two (2) years.
List the name of the rape crisis center under with whom the hospital has a memorandum of understanding: ______
PART B 1. Attach a copy of the Hospital’s sexual assault plan.
2. Provide copy of approved designated trauma center by the Department in accordance with Section 3.90 of the Emergency Medical Services (EMS) Systems Act.
3. Attach copies of appropriate documents distributed to sexual assault survivors that describe:
a) The risk of sexually transmitted diseases and infections, including an evaluation of the risk of contracting human immunodeficiency virus (HIV).
b) The types of medication for sexually transmitted diseases and side effects.
c) The medical procedures, laboratory tests, medication given, and possible contraindications of the medication.
d) The necessity of follow-up visits, examinations, and laboratory tests.
e) The information concerning emergency contraception in accordance with Section 545.95 of the Regulations.
f) The Illinois State Police Medical Forensic Documentation Forms and Discharge Materials, which shall be used as a component of written information distribution. (See Section 545.61(a) of the Regulations.) The facility shall utilize The Illinois State Police Medical Forensic Documentation Forms: Illinois State Police Consent: Collect and Test Evidence or Collect and Hold Evidence, and the Illinois State Police Patient Discharge Materials form. Exam offered for survivors within a minimum of the last seven (7) days of a complaint of sexual assault or who disclosed past sexual assault by a specific individual and were in the care of that individual within a minimum of the last seven (7) days.
g) The drug-facilitated sexual assault testing information, including an explanation of the comprehensive scope of drug screening and the limited time frame within which evidence can be collected. h) Photo documentation consent forms.
i) Written Notice to sexual assault survivors as per 545.100 of the Regulations.
j) Protocol for issuance of a sexual assault services voucher per section 5.2 of the Act. (example of voucher)
4. Describe evidence collection procedures to be taken. The Illinois State Police Medical Forensic Documentation Forms, Patient Consent: Collection and Test Evidence or Collect and Hold Evidence may be used and attached.
5. Describe counseling resources provided to sexual assault survivors. Counseling services shall comply with Section 545.60(a) (9) of the Regulations and Section 2) (c) of Act. Procedure for mandatory reporting requirements pursuant to Section 2) (d) of the Act.
6. Attach a copy of the Emergency Department’s training program for the clinical staff as per [410 ILCS 70/2(a)].
7. Describe the protocol for issuance of a sexual assault services voucher per section 5.2 of the Act.
8. Describe how the hospital will offer the survivor access to a shower, if applicable. PART C
Review and sign the Conditions of Approval:
CONDITIONS OF APPROVAL
The following conditions of approval shall apply to all hospitals providing treatment services to sexual assault survivors. These conditions are enumerated below to ensure that all treatment hospitals are informed and aware of their responsibilities in accordance with the Regulations and the Act. 1. The hospital shall provide hospital emergency services to sexual assault survivors, with the consent of the sexual assault survivor and as ordered by the attending physician, advanced practice nurse or physician assistant in accordance with the Sexual Assault Survivors Emergency Treatment Act and with the Sexual Assault Survivors Emergency Treatment Code (see Section 545.60 of the Regulations).
2. The hospital shall provide emergency services at no direct charge to the survivor. If the survivor is neither eligible to receive services under the Illinois Public Aid Code nor covered by a policy of insurance, the hospital shall seek reimbursement only from the Illinois Department of Healthcare and Family Services (HFS), according to procedures established by HFS for that purpose (Hospital Services, 89 Ill. Adm. Code 148).
3. The hospital shall submit billings to HFS on properly authenticated vouchers supplied by HFS for all eligible survivors for whom hospital emergency services were provided pursuant to its approved Treatment Plan.
4. The hospital shall maintain and preserve all survivor medical records for sexual assault survivors under the age of 18 for a period of 60 years after the sexual assault survivor reaches the age of 18. For sexual assault survivors 18 years of age or older, records shall be retained by the hospital for a period 20 years after the date the record was created.
5. The hospital shall maintain all business and professional records in accordance with acceptable business and accounting practices, and all records shall be legible. Records shall be retained for a period of not less than three years after the date of service or as required by State law, whichever period is longer, except that if an audit is initiated within the required retention period, the records shall be retained until the audit is completed and every exception is resolved.
6. The hospital shall comply with the reporting procedures for sexual assault survivors as required by Section 3.2 of the Criminal Identification Act [20 ILCS 2630].
7. The hospital shall post information in the emergency department concerning crime victim compensation to comply with the Crime Victims Compensation Act [740 ILCS 45].
8. The out-of-state hospital shall consent to the jurisdiction and oversight of the Department, including, but not limited to, inspections, investigations, and evaluations arising out complaints relevant to Act made to the Department per section 2.06 of the Act.
FOR THE HOSPITAL:
Administrator